Investigator, Special Investigations Unit (SIU)

CVS Health • Frankfort, KY

418d • $43,888 - $76,500

About The Position

The SIU Investigator at CVS Health is responsible for conducting investigations to prevent, investigate, and prosecute healthcare fraud and abuse. This role is crucial in recovering lost funds and ensuring compliance with state regulations regarding fraud prevention. The position requires a strong understanding of healthcare fraud dynamics, particularly in behavioral health, and involves collaboration with law enforcement agencies and internal teams to address fraudulent activities effectively.

Requirements

• 3 years of experience working on healthcare fraud, waste, and abuse investigations and audits required.
• 1-3 years of experience working on healthcare fraud, waste, and abuse investigations and audits required or equivalent investigations experience.
• Knowledge of CPT/HCPCS/ICD coding.
• Knowledge and understanding of clinical issues.
• Proficiency in Word, Excel, MS Outlook products, and database search tools.
• Strong communication and customer service skills.
• Ability to effectively interact with different groups of people at different levels in any situation.
• Strong analytical and research skills using healthcare data.
• Proficient in researching information and identifying information resources.
• Ability to utilize company systems to obtain relevant electronic documentation.
• Ability to travel and participate in legal proceedings, arbitrations, depositions, etc.

Nice To Haves

• Credentials such as a certification from the Association of Certified Fraud Examiners (CFE).
• Accreditation from the National Health Care Anti-Fraud Association (AHFI).
• A minimum of three years Medicaid Fraud, Waste and Abuse investigatory experience.
• Billing and Coding certifications such as CPC (AAPC) and/or CCS (AHIMA).
• Knowledge of Behavioral Health policies and procedures is a plus.
• Experience working Behavioral Health fraud cases.

Responsibilities

• Routinely handle cases involving behavioral health or multi-disciplinary provider groups in a prepayment environment.
• Investigate to prevent payment of fraudulent claims committed by insured's, providers, claimants, etc.
• Research and prepare cases for clinical and legal review.
• Document all appropriate case activity in the case tracking system.
• Prepare and present referrals, both internal and external, in the required timeframe.
• Facilitate the recovery of company losses as a result of fraud matters.
• Assist the team in identifying resources and the best course of action on investigations.
• Cooperate with federal, state, and local law enforcement agencies in the investigation and prosecution of healthcare fraud and abuse matters.
• Demonstrate high level of knowledge and expertise during interactions and act confidently when providing testimony during civil and criminal proceedings.
• Give presentations to internal and external customers regarding healthcare fraud matters and CVS Health's approach to fighting fraud.
• Provide input regarding controls for monitoring fraud-related issues within the business units.
• Exercise independent judgment and use available resources and technology in developing evidence, supporting allegations of fraud and abuse.

Benefits

• Full range of medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Employee Stock Purchase Plan.
• Fully-paid term life insurance plan.
• Short-term and long-term disability benefits.
• Numerous well-being programs.
• Education assistance and free development courses.
• CVS store discount and discount programs with participating partners.
• Paid Time Off (PTO) or vacation pay.
• Paid holidays throughout the calendar year.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Health and Personal Care Retailers
• Education Level: Associate degree